Emerald Care Center Tulsa

Based on observation, record review, and interview, the facility failed to ensure wound care was provided as ordered for one (#22) of one sampled resident who was observed for non pressure related wounds. The ADON identified five residents who had non pressure related wounds. Findings: Res #22 had diagnoses which included peripheral vascular disease, non pressure chronic ulcer of right foot, and diabetes. An assessment, dated 02/08/24, documented Res #22's cognition was intact, had no behaviors of rejection of care, was dependent on staff for dressing, personal hygiene, and transfers, had diabetic foot ulcers, and moisture associated skin damage. A physician's order, dated 04/03/24, documented to cleanse wound to right shin and knee with normal saline, pat dry, apply xeroform and cover with a bordered gauze dressing daily. A TAR, dated 04/01/24 through 04/09/24, documented the wound care had not been completed on 04/05/24, 04/06/24, and 04/09/24. On 04/08/24 at 9:47 a.m., Res #22 was asked about the dressing on their right shin dated 04/04/24. They stated they had diabetic sores.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure physician orders for an indwelling urinary catheter and failed to ensure a resident with an indwelling urinary catheter received services to help prevent urinary tract infections for one (#49) of one resident reviewed for catheters. The ADON identified seven residents with an indwelling urinary catheter. Findings: Res #49 had diagnoses which included obstructive and reflux uropathy and benign prostatic hyperplasia without lower urinary tract symptoms. A physician order, dated 12/06/23, documented to perform catheter care and record output every shift. The order was discontinued on 02/27/24. A physician order, dated 12/10/23, documented to change the catheter anchor and bag weekly on Sunday. The order was discontinued on 02/27/24. An admission assessment, dated 12/12/23, documented the resident was cognitively intact, dependent with toileting, and had a urinary catheter. A care plan, dated 12/12/23, documented the resident had an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure a. the correct amount of water was administered via peg tube as ordered by the physician; b. the head of the bed was elevated during administration of water flushes and tube feeding through the peg tube; and c. a dietary recommendation was sent to the physician for one (#8) of one sampled resident who was administered nutrition through a peg tube. 1. Res #8 had diagnoses which included dysarthria (weakness in the muscles used for speech), hemiparesis and hemiplegia (Partial to complete paralysis on one side of the body) following a cerebral infarction. An assessment, dated 01/20/24, documented Res #8's cognition was moderately impaired, was dependent on staff assistance for eating and repositioning, had loss of liquids or solids from mouth when eating or drinking, coughed or choked during meals or when swallowed medications, had difficulty or pain with swallowing, and received nutrition through a peg tube. A physician's order, dated 02/29/24, documented to administer Isosource 1.5 250 ml bolus and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to provide sufficient staff to meet the needs of the residents for six (#7, 14, 16, 17, 27, and #43) of seven sampled residents who were reviewed for sufficient staffing. The corporate administrator identified 53 residents who resided in the facility. Findings: A document titled, Resident Council Minutes, dated 02/27/24, read in part, .Resident not getting medicine on time on weekends .Number of residents who share the concern 8 . The schedule for 03/31/24 was reviewed and compared with punch detail records. The schedule documented one CMA, one RN, and two LPNs were scheduled who had the qualifications to administer medications. 1. Res #7 had diagnoses which included constipation, essential hypertension, GERD, chronic rhinitis, history of venous thrombosis, and chronic pain. A MAR, dated 03/01/24 through 03/31/24 documented the following medications were not initialed as administered as ordered on 03/31/24: daily Vitamin, docusate sodium, Flomax, fluticasone propionate, lidocaine external gel, lisinopril, vitamin B-12,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to post the required staffing information. The corporate administrator identified 53 residents who resided in the facility. Findings: Resident Council Meeting minutes, dated 02/27/24, documented the the staff were not introducing themselves to the residents and they did not know which staff members were working on their hall. The document titled, Resident Council Response form, dated 02/28/24, documented proposed action of a white board for daily nursing assignments. On 04/08/24 at 7:00 a.m., a working schedule with the staff assigned to each hall and shift was in a book at the nurse's station. The working schedule documented the census was 55. There was no white boards with staffing on the walls and the census was not correct. On 04/09/24 at 1:49 p.m., the dry erase board on hall B documented the nurse, CMA, and CNAs assigned to the hall. The board did not document the resident census. On 04/09/24 at 1:51 p.m., CNA #4 was asked about the dry erase board hanging on the wall on hall B. They stated the dry erase…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to administer medications in accordance with physician orders for one (#22) of five sampled residents reviewed for unnecessary medications. The corporate administrator identified 53 residents resided in the facility with 17 residents receiving insulin. Findings: Res #22 had diagnoses which included diabetes mellitus, and anxiety. A physician order, dated 02/28/23, documented to administer Depakote tablet delayed release 125 m.g three times per day at 8:00 a.m., 2:00 p.m., and 8:00 p.m. for anxiety. A physician order, dated 02/28/23, documented to administer Humalog subcutaneous injection according to sliding scale before meals and at bedtime at 6:00 a.m., 11:00 a.m., 4:00 p.m., and 9:00 p.m. A physician order, dated 05/18/23, documented to administer Insulin Glargine subcutaneous injection 59 units twice daily at 6:00 a.m. and 9:00 p.m. for diabetes mellitus. A MAR/TAR for February 2024 documented blanks in the insulin administration for the 6:00 a.m. dose of insulin glargine on 02/06/24, 02/07/24, 02/14/24, and 02/20/24. A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to: a. develop and maintain policies and procedures for the monthly drug regimen review to include time frames for the different steps in the process, b. ensure a physician responded to a monthly medication review for one (#22) of five sampled residents reviewed for unnecessary medications, and c. ensure the facility followed up on requests made on the monthly medication review for one (#14) of five sampled residents reviewed for unnecessary medications. The corporate administrator identified 53 residents resided in the facility. Findings: A Drug Regiment Review policy, dated 2021, documented in part .The physician provides a written response of the report to the facility within one month after the report is sent .The facility maintains copies of signed reports on file for at least one year .Nursing personnel provide a written response to the review within two weeks after the report is received .The facility maintains copies of completed reports on file for at least one year . 1. Res #14 had diagnoses which included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure a resident did not receive unnecessary psychotropic medications for two (#17 and #22) of five sampled residents reviewed for unnecessary medications. The ADON identified eight residents received psychotropic medications. Findings: 1. Res #22 had diagnoses which included depression and anxiety. A physician order, dated 02/28/23, documented to administer Depakote oral tablet 125 mg three times per day for anxiety. A physician order, dated 03/20/23, documented to administer olanzapine 5 mg, one tablet one time per day for anxiety. A monthly drug regimen review, dated 07/04/23, documented a request to reduce the olanzapine and/or Depakote. The medical record did not contain a documented response from the physician. A MAR for July 2023 documented Res #22 received olanzapine 5 mg 27 out of 27 opportunities after the request to reduce was made. A MAR for July 2023 documented Res #22 received Depakote 125 mg 77 out of 81 opportunities after the request to reduce was made. A MAR for August 2023 documented Res #22 received…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to monitor food cooking and holding temperatures to ensure safe temperatures were maintained in the kitchen and on the steam table during meal service. The ADON reported 52 residents received services from the kitchen. Findings: A facility policy titled Food Safety Requirements, reviewed 01/24, read in part, .Factors implicated in foodborne illnesses .inadequate cooking and improper holding temperatures .foods require adequate cooking and proper holding temperatures to reduce the rapid and progressive growth of illness producing microorganisms . The facility food temperature log was reviewed from 03/29/24 through 04/08/24. For this review period, the facility failed to document the holding temperatures for 10 of 33 meals. On 04/10/24 at 9:53 a.m., the DM stated the cook on duty was responsible for logging the holding temperature of each meal in the food temperature log. They stated the DM was responsible for ensuring the cook logged the temperatures.

Based on observation, record review, and interview, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. The ADON identified 52 residents who received meals from the kitchen. Findings: A facility policy titled Food Safety Requirements, reviewed 01/24, read in parts, .It is the policy of this facility to provide safe and sanitary storage, handling, and consumption of all foods .The food service workers .are responsible to adhere to the food safety requirements .Document the temperature of external and internal refrigerator gauges .Refrigerators must be 41 degrees or less . On 04/08/24 at 7:24 a.m., a review of the temperature log sheets documented the temperature of the reach-in coolers and reach-in freezers had not been recorded since 04/05/24. On 04/08/24 at 7:28 a.m., a reach-in cooler was observed to contain packages of tortillas, tomatoes, carrots, cucumbers, shredded cheese, and ham with no dates. On 04/08/24 at 7:35 a.m., the dish machine log was observed on the wall near the dish machine. The log indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure garbage was disposed of properly. The ADON reported 52 residents received services from the kitchen. Findings: On 04/09/24 at 11:30 a.m., the trash can near the handwashing sink was observed to have a box sitting on top of the lid, the box was full of garbage and garbage was falling onto the floor. On 04/10/24 at 9:53 a.m., the DM stated the trash should not be piled up on the trash can lid.

Based on observation, record review, and interview, the facility failed to ensure: a. a surveillance system was in place to routinely identify infections and communicable diseases; b. a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems; c. linens and laundry were processed in accordance with accepted national standards to produce hygienically clean laundry and prevent the spread of infection to the extent possible; and d. soiled linen was handled in a manner to prevent cross contamination. The corporate administrator identified 53 residents who resided in the facility. Findings: A Infection Control - Surveillance for Infection policy, revised January 2024, read in parts, .The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infections, to guide appropriate interventions, and to prevent further infections .Analyze the data to identify trends .Compare the rates to previous months in the current…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to designate an individual as the infection preventionist. The corporate administrator identified 53 residents resided in the facility. Findings: On 04/08/24 at 8:15 a.m., the DON was asked to identify their infection preventionist. They stated they believed it was RN #1. On 04/11/24 at 9:20 a.m., RN #1 was contacted via phone. They were asked if they were the IP for the facility. They stated they had the required certification but had not been asked to perform the duties of the IP for the facility. They stated they were unsure who the IP was. On 04/11/24 at 11:23 a.m., the corporate administrator stated RN #1 had the IP credentials. They stated the DON also had the credentials. When asked who was designated and acting as the IP the corporate admin was unable to state an employee.

Based on record review and interview, the facility failed to offer influenza vaccinations for four (#17, 22, 27, and #43) of five and pneumococcal vaccinations for five (#8, 17, 22, 27, and #43) of five sampled residents reviewed for vaccinations. The corporate administrator identified 53 residents resided in the facility. Findings: A facility influenza immunization policy, revised 01/2024, documented in part .Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees .Prior to the vaccination, the resident .will be provided information and education regarding the benefits and potential side effects of the influenza vaccine .Provision of such education shall be documented in the .medical record .For those who receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the .medical record .A resident's refusal of the vaccine shall be documented . A facility pneumococcal immunization policy, revised 01/2024, documented in part .prior to or upon…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure a kitchen reach-in refrigerator was in good repair. The ADON reported 52 resident received services from the kitchen. Findings: A facility policy titled Food Safety Requirements, reviewed 01/24, read in parts, .It is the policy of this facility to provide safe and sanitary storage, handling, and consumption of all foods .The food service workers .are responsible to adhere to the food safety requirements .Document the temperature of external and internal refrigerator gauges. Refrigerators must be 41 degrees or less .If temperatures are out of range, notify maintenance and follow facility policy for food disposal . On 04/08/24 at 7:24 a.m., the temperature of a reach-in cooler was observed to be 73 degrees Fahrenheit. The daily temperature monitoring log that was hanging on the door did not document the temperature of the refrigerator had been recorded since 04/05/24. The refrigerator was observed to contain cartons of milk, lettuce, and tomatoes. The items in the refrigerator did not feel cold. On 04/08/24 at 10:40…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure residents were treated with dignity for one (#44) of three residents sampled for dignity. The DON reported the census was 53. Findings: Resident #44 had diagnoses which included major depressive disorder and diabetes mellitus. A quarterly assessment, dated 03/29/24, documented the resident was cognitively impaired for daily decision making and was dependent on staff for assistance with eating. On 04/08/24 at 8:05 a.m., Resident #44 was seated in the dining room, they were observed to spill coffee on their shirt, pants, table, and breakfast plate. CNA #1 was in the dining room and went to Resident #44 and asked if they were okay, the resident responded that they were okay. On 04/08/24 at 8:33 a.m., Resident #44 was seated in the dining room, their shirt and pants were still wet, and the breakfast plate was still covered with coffee. Resident #44 stated that things like this happen all the time. Resident #44 also stated they would like clean clothes and they were still hungry. They stated they were unsure if the staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to update the care plan related to hospice services for one (#9) of two sampled resident reviewed for hospice services. The ADON identified five residents who received hospice services. Findings: A Hospice Services Facility Agreement policy, revised January 2024, read in parts, .The facility will under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Res #9 had diagnoses which included congestive heart failure, atrial fibrillation, and chronic kidney disease. A physician order, dated 09/18/23, documented hospice to evaluate and treat. A significant change assessment, dated 11/27/23, documented the resident was moderately cognitively impaired, dependent with most ADLs, and received hospice services. A care plan, revised 04/08/24, had no documentation of hospice services. On 04/10/24 at 9:30…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure oxygen cylinders were stored properly. The DON reported the census was 53. Findings: On 04/10/24 at 1:38 p.m., an unattended wheelchair was observed in the hallway, an oxygen cylinder was sitting upright in the seat of the wheelchair with the top leaned against the back of the wheelchair. On 04/10/24 at 1:41 p.m., an unknown staff member removed the cylinder from the wheelchair and placed the cylinder standing upright in the hallway. The staff member then took the wheelchair and walked off leaving the unsecured cylinder in the hallway unattended. On 04/10/24 at 1:43 p.m., the same unknown staff member returned with the wheelchair and placed the oxygen cylinder back in the seat of the wheelchair. On 04/10/24 at 1:48 p.m., LPN #3 stated that oxygen cylinders should be stored securely in a rack so they cannot be knocked over. On 04/10/24 at 1:54 p.m., the DON stated oxygen cylinders should be stored per manufacturers guidelines and they should not be left balanced in the seat of a wheelchair

Based on record review and interview the facility failed to complete required nurse aide yearly performance reviews for one (CNA #1) of three direct care employee files reviewed. The corporate administrator identified 53 residents who resided in the facility. Findings: CNA #1's personnel file documented they had been hired on 05/07/22. There was no documentation a skills performance review had been completed. On 04/11/24 at 1:30 p.m., the HR director stated CNA #1's personnel file was missing. They stated they had a new administrator and DON at the time CNA #1 was rehired.

Based on record review and interview, the facility failed to ensure labs were completed as ordered for one (#60) of five residents reviewed for unnecessary medications. The DON reported the census was 53. Findings: Res #60 had diagnoses which included diabetes mellitus and hypertension. A physician's order dated 12/28/23 documented that a CBC, CMP, B-12, TSH, A1C and a lipid panel were ordered for Res #60. The status of the order documented it had been completed. A review of Res #60's medical records did not document lab results from 12/28/23. On 04/10/24 at 11:57 a.m., MDS coordinator #1 stated the ordered labs had not been completed. On 04/11/24 at 9:09 a.m., LPN #4 stated she was unsure of the process for obtaining labs in the facility. On 04/11/24 at 10:20 a.m., LPN #1 stated the lab company would automatically draw any labs that had been put in their system, and that nursing staff was responsible for ensuring labs were completed as ordered. On 04/11/24 11:36 a.m., the ADON stated the nurse that takes the order for lab work should put it in the computer and the lab company will…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to maintain an antibiotic stewardship program for one (#4) of one sampled residents reviewed for antibiotic use. The ADON identified three residents were receiving antibiotics. Findings: An infection control policy, revised January 2024, documented in part .Facility nursing staff will initiate the appropriate clinical data review by completing the specific FORMS evaluations .that will be implemented once an antibiotic is ordered to determine if the utilization of the antibiotic is justified and meets criteria. The IP nurse will review the completion of the individuals triggered FORM to ensure complete and accurate data collection .The IDT will review new antibiotic orders in the clinical morning meeting, identified issue will be acted upon immediately by the IP nurse . Res #4 had diagnoses which included COPD and chronic respiratory failure. A physician order, dated 04/05/24, documented to administer amoxicillin-potassium clavulanate tablet 875-125 mg one tablet two times daily for infection/rep for ten days. Progress notes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interview, the facility failed to maintain a comfortable room temperature for three (#7, 8, and #9) of three sampled residents whose room temperatures were obtained. The Administrator identified 68 residents resided in the facility. Findings: A Facility Responsibilities policy, created 01/2024, read in parts, .The facility must provide .Comfortable and safe temperature levels .maintain a temperature range of 71 to 81 degrees F . On 03/14/24 at 11:12 a.m., Resident #7 was observed in bed wearing a sweatshirt and covered with two blankets. A heavy cold breeze was noted coming from their overhead vent. When asked about the temperature in their room they stated it was always very cold and they wished the air could be turned down. On 03/14/24 at 11:36 a.m., Resident #9 was observed in bed with two blankets pulled up to her neck and a heavy cold breeze was noted coming from their overhead vent. Resident #57 was asked how they felt about the temperature in their room. They stated, It's way too cold. We've told them but they won't stop the air. On 03/14/24 at 12:15…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure there was ongoing communication with the dialysis center for one (#1) and ongoing assessments of residents before and after dialysis treatments for three (#1, 3, and #4) of four sampled residents reviewed for dialysis care. The Administrator identified 68 residents resided in the facility. The were six residents receiving dialysis treatments. Findings: A Special Needs policy, created 01/2024, read in part, .This policy pertains to the following needs . and dialysis .The facility will communicate relevant information with outside providers to ensure safe continuous care of the resident . A Dialysis Care policy, revised 09/01/21, read in part, .All residents receiving dialysis will be assessed before and after dialysis treatment . 1. Resident #1 had diagnoses that included type 1 diabetes and end stage renal disease. Resident # 1 had physicians' orders, dated 02/21/24, to receive dialysis treatments 3 times a week on Monday, Wednesday, and Friday; and to obtain and chart pre- and post-dialysis assessments with vital…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to facilitate the inclusion of residents' representative in their care plan conferences for two (#1 and #2) of three sampled residents whose care plan conferences were reviewed. The Administrator identified 68 residents resided in the facility. Findings: A Care Plan Process policy, last revised 9/2019, read in parts, .every effort will be made to involve the resident and family or responsible party including private duty or nursing assistant, in the development, implementation, maintenance, and evaluation of the resident plan of care .families, or legal representatives will be notified of the care planning conference in writing at least seven (7) days prior to the conference .Participation in the resident care planning process will be documented by obtaining the signature of the resident, family, or legal representative . 1. Resident #2 had diagnoses that included type 2 diabetes and stage 4 pressure ulcer of sacral region. On 03/14/24 at 1:50 p.m., during an interview with Resident #2's family member, they stated they had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to accommodate a residents' need for adaptive equipment that would allow the highest possible level of physical functioning and well-being for one (#2) of one sampled resident reviewed for accommodation of needs. The Administrator identified 68 residents resided in the facility. Findings: A Bed Rails policy, created 01/2024, read in parts, .The facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices . A Facility Responsibilities policy, created 01/2024, read in parts, .5. Self-determination .i. The facility must consider the view of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility . Resident #2 had diagnoses that included type 2 diabetes and stage 4 pressure ulcer of sacral region. There was no physician's order on file for Resident #2 to have a trapeze placed on their…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure resident representatives were notified of changes in condition for one (#1) of three sampled resident who were reviewed for notification of change. The Administrator identified 68 residents resided in the facility. Findings: A Facility Responsibilities policy, created 01/2024, read in parts, .A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority the resident representative(s) when there is .An incident involving the resident .A significant change in the resident's physical, mental, or psychosocial status .A need to alter treatment . Resident #1 had diagnoses which included type1 diabetes and end stage renal disease. A facility incident report, dated 02/21/24 at 4:54 p.m., documented Resident #1 slipped out of their wheelchair trying to stand up. The incident report or nurse progress notes did not document the resident's POA had been notified. A facility incident report, dated 02/22/24 at 1:29 p.m., documented Resident #1 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure wound assessments were completed for one (#6) of three sampled residents whose wound assessments were reviewed and failed to follow infection control practices during wound care for one (#5) of one sampled resident whose wound care was observed. The administrator identified 68 residents resided in the facility. Findings: A Documentation Standards for Wound policy, last revised 01/2024, read in parts, .Resident with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection .it is important that documentation addresses .progress toward healing and identification of potential complications .description of dressings and treatments . 1. Resident #6 had diagnoses that included stage 2 pressure ulcers to left ischium, left hip, and right ischium. A physicians' order, dated 03/08/24, documented treatment order to cleanse left ischium, left hip, and right ischium wounds with NS/dakins/wound cleanser, apply medihoney, cover…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure: a. residents received baths as requested and according to schedule for two (#9 and #14) of three sampled residents reviewed for baths; b. medications were administered as ordered by a physician for two (#15 and #17) of three sampled resident reviewed for following physician orders; and c. blood sugars levels were obtained as ordered by a physician for two (#15 and #17) of three sampled residents reviewed for following physician orders. A facility census report, dated 01/31/24, documented 66 residents resided in the facility. Findings: A Medication Administration and General Guidelines policy, dated 2021, documented medications were to be administered as prescribed and the resident's medication administration record was to be initialed by the person who administered the medication. A Resident Rights policy, dated November 2017, documented residents had the right to receive services to meet their needs and preferences. 1. Resident #9 had diagnoses which included a fracture of the right tibia and end…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to report an allegation of sexual abuse to the Oklahoma Stated Department of Health. A facility census report, dated 01/31/24, documented 66 residents resided in the facility. Findings: Resident #13 had diagnoses which included chronic obstructive pulmonary disease and Parkinson's disease. A facility policy, titled Abuse, Neglect, and Exploitation, dated November 2017, documented allegations of abuse were to be reported to the state survey agency within five working days of the alleged incident. A facility document, titled Concern Form, dated 06/28/26 [sic], documented a family member reported an alleged incident of sexual abuse to the director of nursing on 06/28/23. An Adult Protective Services investigation report, dated 11/06/23, documented an APS worker visited the facility on 10/31/23 and discussed the alleged incident with Employee #2. Resident #13's medical records and facility records were reviewed for documentation of an investigation regarding the Concern Form, dated 06/28/26. No investigative documentation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to conduct a thorough investigation of a report of alleged sexual abuse for one (#13) of three sampled residents reviewed for abuse. A facility census report, dated 01/31/24, documented 66 residents resided in the facility. Findings: Resident #13 had diagnoses which included chronic obstructive pulmonary disease and Parkinson's disease. A facility policy, titled Abuse, Neglect, and Exploitation, dated November 2017, documented suspected abuse would be investigated immediately and include interviews of residents, staff, and visitors that were in the area and document the entire investigation. A facility document, titled Concern Form, dated 06/28/26 [sic], documented Employee #1 had written that Resident #13's family member reported the resident had said a male aide had cupped their breast during a shower. It further documented Employee #1 was designated to act on the issue and was assigned to them on 06/28/23. It documented Employee #1 had met with the resident who stated they were not comfortable with a male aide providing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident was not involuntarily discharged without notice and right to appeal and failed to document a discharge in a resident's medical record for one (#8) of three sampled resident reviewed for discharges. A facility Length of Stay By Discharge Reason Report, dated [DATE] through [DATE], documented 37 residents discharged from the facility during the specified period. Findings: Resident #8 had diagnoses which included fracture of the right tibia and schizoaffective disorder. A facility policy, titled Transfer and Discharge from the Facility Policy, dated [DATE], read in part, .The rights of residents who voluntarily or involuntarily are discharged from the facility will be upheld and that a resident will not be involuntarily discharged unless the circumstances meet specific criteria defined by regulations and laws. The facility will make every effort to provide care and services to the residents it serves .The objective of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to provide a notice of transfer and a notice of discharge for one (#8) of three sampled residents reviewed for discharges. A facility Length of Stay By Discharge Reason Report, dated 10/01/23 through 11/30/23, documented 37 residents discharged from the facility during the specified period. Findings: Resident #8 had diagnoses which included fracture of the right tibia and schizoaffective disorder. A facility policy titled Transfer and Discharge from the Facility Policy, dated May 2017, read in part, .Notice of transfer. Before a facility transfers or discharges a resident, the facility must - (i) Notify the resident and resident's representative(s) of the transfer or discharge and reasons for the move in writing . A progress note, dated 10/04/23, documented the resident had been transferred to an acute care hospital for psychiatric evaluation on the order of APRN #1. A meeting minutes, dated 10/10/23, documented a conference call was attended by Employee#1 [former facility DON], Employee #2 [former facility administrator],…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to provide a bed hold policy to a resident prior to transfer for one (#8) of three sampled residents reviewed for discharges. A facility Length of Stay By Discharge Reason Report, dated 10/01/23 through 11/30/23, documented 37 residents discharged from the facility during the specified period. Findings: Resident #8 had diagnoses which included fracture of the right tibia and schizoaffective disorder. A progress note, dated 10/04/23, documented the resident had been transferred to an acute care hospital for psychiatric evaluation. On 02/08/24 at 10:45 a.m., the Administrator stated that they had not found documentation that Resident #8 had received a bed hold policy, notice of transfer, notice of discharge, or a discharge summary prior to or after departing the facility on 10/04/23. At 1:52 p.m., the DON stated there was no documentation that Resident #8 had been given a copy of the bed hold policy. They stated they did not find a bed hold policy in the resident's medical records.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to allow a resident's return to the facility after being transferred to a local hospital for a mental health evaluation for one (#8) of three sampled residents reviewed for discharges. A facility Length of Stay By Discharge Reason Report, dated 10/01/23 through 11/30/23, documented 37 residents discharged from the facility during the specified period. Findings: Resident #8 had diagnoses which included fracture of the right tibia and schizoaffective disorder. A facility policy, titled Transfer and Discharge from the Facility Policy, dated May 2017, read in part, .The rights of residents who voluntarily or involuntarily are discharged from the facility will be upheld and that a resident will not be involuntarily discharged unless the circumstances meet specific criteria defined by regulations and laws. The facility will make every effort to provide care and services to the residents it serves .The objective of the transfer/discharge policy is to ensure that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure staff notified residents' representatives when a change in condition occurred for two (#1 and #120) of three sampled residents reviewed for notifications. The Resident Census and Conditions of Residents report, dated 02/22/23, documented 63 residents resided in the facility. Findings: A Notification of Condition Change policy, revised on 12/17/18, read in part, .A change in a resident's condition will be reported to the physician and responsible party in a timely manner . 1. Resident #1 had diagnoses which included chronic pain and generalized anxiety disorder. An Order Note, dated 01/20/23, documented Resident #1 received a new order from the physician to treat for anxiety. There was no documentation the resident's representative had been notified. An Alert Note, dated 01/31/23 at 10:04 p.m., documented Resident #1 was complaining of pain and the staff received a new order from the physician. There was no documentation the resident's representative had been notified. An Order Note, dated 02/01/23 at 4:11 p.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to provide the appropriate liability notice prior to a resident coming off of skilled services for three (#21, 44, and #48) of three sampled residents reviewed for beneficiary notices. The DON identified 23 residents who were discharged from Medicare Part A services with benefit days remaining in the past six months. Findings: Resident #21's last covered day of Part A service was 12/08/22. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Resident #48's last covered day of Part A service was 12/14/22. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Resident #44's last covered day of Part A service was 02/16/23. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. There was no SNF ABN of non-coverage provided to the residents or residents' representatives. On 02/24/23 at 11:31 a.m., the Administrator stated SNF ABNs were a business office…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to provide maintenance services necessary to ensure the following: a. floor tile was in good repair and not a trip hazard, b. wall paper was not peeling from the walls in Resident rooms and common areas, c. sheet rock was not damaged with cracks and deteriorating in common areas, and d. a clean and sanitary home like environment. The Resident Census and Condition of Residents, dated 02/22/23, documented 63 residents resided in the facility. Findings: On 02/24/23 at 9:30 a.m., a family representative stated that the room mate smeared excrement on the privacy curtain between the beds in room [ROOM NUMBER]. They stated a report to previous administrator was made and no action was taken. On 02/24/23 at 9:56 a.m., a brown unknown substance was observed on the wall above the trash can located in room [ROOM NUMBER] by the bedside. A brown substance was observed on the lower section of the privacy curtain located between beds A and B in the room.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to: a. provide bathing assistance for two (#65 and #120) and, b, provide assistance to a dependent resident during the lunch meal service for one (#9) of 24 sampled residents reviewed for ADL assistance. The Resident Census and Condition of Residents, dated 02/22/23, documented 63 residents resided in the facility. Findings: A Dining Experience policy, revised 01/02/19, read in parts, .The dining experience will be safe and satisfying for the resident .Residents are assisted in a dignified and timely manner . 1. Resident #9 had diagnoses which included anoxic brain damage and quadriplegia. An admission Resident Assessment, dated 10/27/22, documented Resident #9 had moderately impaired cognition and required total dependence of one staff physical assist for the task of eating. A Quarterly Resident Assessment, dated 01/23/23, documented Resident #9 had moderately impaired cognition and required total dependence of one staff physical assist for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interviews the facility failed to: a. obtain weekly measurements of a pressure ulcer as ordered, b. ensure an effect communication for wound care orders from a third party contract provider was in place, c. provide wound care as ordered and d. assess and monitor a pressure ulcer for changes for one (#20) of three sampled resident reviewed for pressure ulcers. The Resident Census and Conditions of Residents report, dated 02/22/23, documented 15 residents with pressure ulcers. Findings: A Prevention of Skin Breakdown policy, revised 10/01/21, read in parts, .It is the policy of this facility to implement interventions to assist in preventing skin breakdown .Weekly skin evaluation is to be completed for each resident by a licensed nurse . The facility contract with Contract Agency #1, dated 01/19/23, read in parts, .Contract Services shall mean the services which Provider commonly performs within Provider's scope of practice .nursing services (including but not limited to basic skin care .non-skilled custodial care .Interdisciplinary Team shall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure an RN worked eight consecutive hours a day, seven days a week for four of 31 days reviewed in the month of January 2023. The Resident Census and Conditions of Residents report, dated 02/22/23, documented 63 residents. Findings: The time cards for RN coverage for the month of January 2023 documented: a. RN #2 worked from 10:09 a.m. to 5:12 p.m. on 01/02/23 b. No RN on 01/21/23 c. RN #1 worked from 2:17 p.m. to 9:00 p.m. on 01/23/23 and d. RN #1 worked from 3:13 p.m. to 8:10 p.m. and RN #2 worked from 1:20 p.m. to 4:31 p.m. on 01/27/23. On 02/27/23 at 1:22 p.m., the DON was asked the policy for ensuring RN coverage at least eight consecutive hours every day. She stated she did not know the specific policy, but she knew it was a requirement. The DON was asked if the facility had met the requirements for the above dates. She stated she thought there would have been coverage. On 02/27/23 at 1:25 p.m., the DON stated the 21st did match no RN coverage based off of what the Staffing Coordinator provided her. She stated she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to: a. medications were administered as ordered for two (#20 and #56) of five sampled residents reviewed for unnecessary medications, and b. controlled medications awaiting destruction were verified by two licensed staff for 15 (#17, 35, 52, 69, 70, 71, 72, 73, 75, 76, 77, 78, 79, 80 and #81) of 15 sampled residents whose discontinued medications were observed. The Resident Census and Conditions of Residents report, dated 02/22/23, documented 63 residents. Findings: A Drug Destruction policy, dated 2021, read in part, .In the event that the facility must destroy medications .the facility will adhere to the rules and regulations of their specific State Health Department as well as any other regulatory body including but not limited to the Drug Enforcement Agency . A Medication Administration and General Guidelines policy, dated 2021, read in parts, .Medications are administered as prescribed . 1. Resident #20 had diagnoses which included type…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure an effective administration for the coordination and continuity of care for one (#20) of one sampled resident reviewed for third party contract services. The Resident Census and Conditions of Residents report, dated 02/22/23, documented 63 residents. Findings: Resident #20 had diagnoses which included osteomyelitis and iron deficiency anemia. An Activities note, dated 02/01/23 at 4:43 p.m., read in parts, .[Contract Agency #1 Case Manager] PROVIDED A .PHONE NUMBER TO TEXT .AND THE ON CAL PHONE NUMBER .PLEASE LEAVE A VOICEMAIL IF NO ANSWER .RECEIVED ORDER FOR WOUND CARE OF SACRUM AND LEFT HEEL. THESE ORDERS ARE FROM 1-20-23 WHICH THIS FACILITY DID NOT RECEIVE. ORDERS PUT IN AS OF TODAY BY THIS NURSE . The note was signed by the Wound Care Nurse. An Order Note, dated 02/15/23 at 12:38 p.m., documented discontinue lispro six units at meals and follow sliding scale before meals and at bedtime. There was no documentation this was acted on. On 02/22/23 at 9:38 a.m., during the Entrance Conference, the DON stated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to: a. provide wound care in a manner which prevented cross contamination for one (#20) of three sampled residents reviewed for pressure ulcers, and b. implement their infection control policy for a system for regular surveillance of all infections. The Resident Census and Conditions of Residents report, dated 02/22/23, documented 63 residents. Findings: An Infection Control policy, revised 06/07/20, read in parts, .a system for regular surveillance and reporting of all infections. This included the collection, analysis, interpretation, and dissemination of data .To detect infections, plan control activities, and identify and manage potential outbreaks of disease .Track new infections each month .Differentiate between nosocomial and community acquired infections .Analyze listing for potential outbreaks .Review and analyze data monthly to identify trends . 1. Resident #20 had diagnoses which included osteomyelitis and iron deficiency anemia. A Physician Order, start date 02/17/23, documented wound care orders;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to: a. ensure residents were offered the pneumonia vaccine for one (#47) and b. ensure residents were offered the flu vaccine annually for three (#14, 21, and #47) of five sampled residents reviewed for vaccinations. The Resident Census and Conditions of Residents report, dated 02/22/23, documented 63 residents. Findings: An Influenza Vaccination policy, undated, read in parts, .It is our policy to offer our residents .annual immunization against influenza .The resident's medical record will include documentation that the resident and/or resident's representative was provided education regarding the benefits and potential side effects of immunization, and that the resident received or did not receive the immunization due to medical contraindication or refusal . A Pnuemococcal Vaccine policy, undated, read in parts, .It is our policy to offer our residents .immunization against pnuemococcal disease .The resident's medical record shall include documentation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to implement: a. A process for tracking and securely documenting the COVID-19 vaccination status of all staff and residents The Resident Census and Conditions of Residents report, dated 02/22/23, documented 63 residents. Findings: A COVID-19 policy and procedure, dated 12/27/22, read in parts, .all staff are offered and fully vaccinated with either the Primary Series refers to staff who have received a single-dose vaccine or all required doses of multi-dose vaccine for COVID-19 .or have an approved exemption under religious or medical condition and/or beliefs . Medical Exemptions and Temporary Delays .Medical exemption documentation when appropriate will specify which authorized or licensed COVID-19 vaccine is clinically contraindicated for the staff member and the recognized clinical reasons for the contraindication . Process for tracking staff vaccine status .each staff member's vaccination status .any staff member who has obtained any booster doses .staff who have been granted an exemption from vaccination .staff whom…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a baseline care plan had been completed within 48 hours of admission for one (#2) of three sampled residents reviewed for admission assessments. The DON identified 20 residents were admitted within the past 30 days. Findings: A Baseline Care Plan policy, dated 11/17, read in parts, .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .The baseline care plan will .Be developed within 48 hours of a resident's admission . Resident #2 was admitted to the facility on [DATE], with diagnoses which included dementia, seizures, and depression. The clinical record did not contain documentation a base line care plan had been completed within 48 hours of admit. On 11/02/23 at 10:45 a.m., the DON was asked if a base line care plan had been completed. The DON stated they couldn't find…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to develop a comprehensive care plan for dialysis for one (#47) of of one sampled resident reviewed for dialysis services. The Resident Census and Conditions of Residents report, dated 02/22/23, documented nine residents received dialysis services. Findings: A Care Plan Process policy, revised 02/19, read in parts, .The plan of care must describe the services that are to be furnished to attain the resident's highest practicable physical, mental, and social well-being .Plans of care have key areas, to include but not limited to .Medications .Treatments .Daily Care Needs . Resident #47 had diagnoses which included dependence on renal dialysis. A Five Day Resident Assessment, dated 11/29/22, documented the resident received dialysis while a resident of the facility. A Quarterly Resident Assessment, dated 01/11/23, documented the resident received dialysis while a resident of the facility. A Care Plan, last revised 01/06/23, read in parts, .Focus .DIALYSIS: I am at risk for COVID 19 due to going out into the community for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to fully complete an admission assessment for one (#20) of three sampled residents reviewed for admission assessments. The Resident Census and Conditions of Residents report, dated 02/22/23, documented 63 residents. Findings: Resident #20 was admitted to the facility on [DATE]. A Nursing admission Data Collection form, dated 01/19/23, was blank in the following areas: a. Reason for admission b. Lifestyle c. Height and Weight d. Oral Status e. History of skin issues f. Skin issue site, description, type, and measurements g. Neurological h. Cardiovascular I. Respiratory- the only section filled out was oxygen saturation j. Gastrointestinal k. Foot care l. Antibiotic Stewardship m. Pain n. Braden Scale o. Bladder and Bowel p. Fall risk q. Elopement risk and r. Safety. The form was not signed by any staff member. On 02/24/23 at 8:14 a.m., the DON was asked who was responsible for filling out the admission data collection form. She stated, I would think…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to obtain physician ordered Pre/Post dialysis vitals and weights for one (#47) of one sampled resident reviewed for dialysis. The Resident Census and Conditions of Residents report, dated 02/22/23, documented nine residents received dialysis services. Findings: A Dialysis Care policy, revised 09/01/21, read in parts, .Residents ordered dialysis therapy will be monitored and documentation will be maintained in the medical record. All residents receiving dialysis will be assessed before and after dialysis treatment and for compliance with their individualized plan of care All residents receiving dialysis treatment will have their access site assessed every shift . Resident #47 had diagnoses which included dependence on renal dialysis. A Physician Order, start date 12/29/21, documented obtain and chart Pre/Post dialysis vitals and weight upon return from dialysis two times a day every Monday Wednesday and Friday. The September 2022 TAR documented blanks for the above order on 09/07 and 09/18 for the 7:00 a.m.- 11:00 a.m. shift,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure a monthly drug regimen review was completed by a licensed pharmacist for one (#32) of five sampled residents reviewed for unnecessary medications. The Resident Census and Condition of Residents report, dated 02/22/23, documented 63 residents resided in the facility. Findings: A Medication Regimen Review policy, dated 5/22, read in part, .The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist .The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and the reports acted upon . Resident #32 had diagnoses of type two diabetes, hypertension, and depression. Resident #32's Physician Order Summary documented Oxycodone HCl oral tablet 10 MG effective on 02/11/23, hydroxyzine HCl oral tablet for anxiety effective 02/11/23, aspirin oral capsule 81 MG effective 02/11/23 , and sertraline HCl tablet 50 mg for depression effective 10/12/22. The facility did not provide any documentation the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure the physician responded to a GDR for one (#37) of five sampled residents reviewed for unnecessary medications. A Resident Census and Conditions of Residents report, dated 02/22/23, documented 26 residents received psychoactive medications. Findings: Resident #37 had diagnoses which included neurotic depression. A Medication Regimen Review, dated 01/06/23, read in part, .Gradual Dose Reduction Attempt .Abilify 5 mg daily .Recommendation: Do you feel a reduction could be attempted on the above medication . There was no documentation the physician had been notified of or responded to the recommendation. A Quarterly assessment, documented Resident #37 received an antipsychotic on a routine basis and no GDR had been attempted. On 02/27/23 at 11:25 a.m., the DON was asked how staff ensured GDRs were acted upon/responded. She stated she wasn't sure. On 02/27/23 at 2:06 p.m., the DON stated they were unable to find a physician response to Resident #37's GDR.

Based on interview, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for the residents competently during both day-to-day operations and emergencies. The Resident Census and Conditions of Residents report, dated 02/22/23, documented 63 residents. Findings: On 02/22/23 at 9:38 a.m., the DON was asked to provide the facility assessment. On 02/27/23 at 6:57 a.m., the DON was asked to verify the facility did not have an up to date facility assessment. She stated she thought the Administrator had provided it and she would check. On 02/27/23 at 7:42 a.m., the DON stated the Administrator had left some papers on her desk to be completed for the facility assessment. She was asked to verify the facility assessment had not been completed. She stated, No.

Based on record review and interviews, the facility failed to ensure a PICC line for IV antibiotic administration was placed in a timely manner by a third party contract service for one (#20) of one sampled resident reviewed for third party contract services. The DON identified two residents who received services from Contract Agency #1. Findings: The facility contract with Contract Agency #1, dated 01/19/23, read in parts, .Contract Services shall mean the services which Provider commonly performs within Provider's scope of practice .nursing services .including but not limited to basic skin care .non-skilled custodial care .Interdisciplinary Team shall mean the [Contract Agency #1] program team, which is responsible for controlling the delivery, quality, and continuity of care to Participants. The Interdisciplinary Team's responsibilities include, but are not limited to, assessing a prospective Participant's level of care needs, developing and implementing a treatment plan for each Participant, and authorizing Contract Services which meet the specific needs of each Participant .…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure records were accessible and complete for one (#20) of 24 sampled residents whose records were reviewed. The Resident Census and Conditions of Residents report, dated 02/22/23, documented 63 residents. Findings: Resident #20 had diagnoses which included osteomyelitis and iron deficiency anemia. A Nursing admission Data Collection form, dated 01/19/23, documented Resident #20 had a current skin issue but failed to document what the skin issue was, where it was located, description of the skin issue or measurements of the skin issue. A Physician Order, start date 01/25/23, documented weekly skin observation tool one time a day every Wednesday. A Skin/Wound Weekly Observation form, dated 01/25/23, documented Resident #20 did have current skin issues, however it failed to document the site of the skin issue, description, measurements, or staging. It documented Contract Agency #1 was providing wound care. The note was signed by LPN #5. An Order Note, dated 02/02/23 at 2:00 p.m., read in parts, .Measure wounds weekly. Call…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, the facility failed to maintain documentation of the vaccination status of each resident to include exemptions for unvaccinated residents for 63 residents who resided in the facility. The Resident Census and Conditions of Residents report, dated 02/22/23, documented 63 residents. Findings: A COVID-19 policy, revised 09/27/22, read in parts, .Each resident .are offered the COVID-19 vaccine and any Booster shots following unless the immunization is medically contraindicated . The DON was asked to provide a list of all residents and their COVID-19 vaccination status on: A. 02/22/23 at 9:42 a.m. during the Entrance Conference, B. 02/23/23 at 8:52 a.m. and C. 02/23/23 at 10:35 a.m. They stated they were not very hopeful, but would look for it. On 02/23/23 at 3:02 p.m., the Administrator was informed the survey team had not been provided a list of all residents and their COVID-19 vaccination status. On 02/24/23 at 1:27 p.m., the DON stated they were unable to locate any documentation of exemptions for unvaccinated residents. They stated when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.